[Therapeutic modalities and economic assessment in the treatment of superficial basal cell carcinomas and multiple actinic keratoses by French dermatologists]. / Evaluation médico-économique de la prise en charge des carcinomes basocellulaires superficiels et des kératoses actiniques multiples par les dermatologues français.

INTRODUCTION: To date, no prospective studies have been conducted in France describing the management of actinic keratoses (AK) and superficial basal cell carcinomas (sBCC). The aim of the present study was to describe the therapeutic modalities for AK and sBCC adopted by French dermatologists and to determine the direct annual medical costs. PATIENTS AND METHODS: This was a prospective, observational study conducted in France between January and June 2004 in a random selection of representative dermatologists (n=202). The first 5 adult patients seen for one or more sBCCs and the first patient with at least 4 AKs over a period of four non-consecutive weeks were included in the study. The following data were recorded using a standardized questionnaire at inclusion: date of birth, gender, habitat, professional activity, social insurance regimen, site, number and maximum size of lesions. The therapeutic modalities, the physicians involved and the laboratory examinations during the 3 months following diagnosis were recorded prospectively. Medical management costs were calculated taking into account the usual parameters (e.g. French nomenclature of medical acts). RESULTS: 512 patients with sBCC (mean age: 69 years; sex-ratio M/F: 0.92) were included in the study. sBCC was isolated in 80% of cases, measured less than 2 cm in 90%, and was located on the head/neck in 51% and on the trunk in 37%. Histological confirmation of diagnosis of BCC was obtained in 85% of cases. Treatment comprised surgical excision in 70% of cases, cryotherapy in 13%, topical therapy in 7% and curettage/electrodessication in 4%. Clinical follow-up was performed in 79% of cases. The mean cost per patient over 3 months was 139 euros (CI95%: 125-153). In addition, 226 patients with AK (mean age: 76 years; sex-ratio M/F: 2.1) were included in the study. AKs were located on the head/neck in 74% of cases and on the trunk in 6%. Treatment consisted of cryotherapy in 92% of cases. The mean cost per patient over 3 months was calculated at 85 euros (CI95%: 71-99). An on-site audit of 5% of the investigators gave a concordance rate of 98.8%. DISCUSSION: This is the first study conducted in France to evaluate both the medical approach and treatment costs of sBCC and AK. Finally, the mostly surgical treatment of sBCC observed is in accordance with the recent French ANAES guidelines. When extrapolating the results of the present study, the annual cost of treatment of sBCC by French dermatologists may be estimated at between 10.2 and 10.6m euros.

[Efficacy and safety of 5% imiquimod cream in external genital warts: a 6 month follow-up evaluation]. / Efficacité et tolérance de l'imiquimod crème 5% dans le traitement des condylomes acuminés externes: résultats d'un suivi à 6 mois.

INTRODUCTION: One of the main issues raised by the management of external genital warts is their potential risk of recurrence. However, nearly all studies assessing recurrences have been conducted with a 3 month follow-up. Since the latency of the human papillomavirus is long, such 3 month follow-up might be too short to detect the true recurrence rate. We therefore conducted a study evaluating patients with external genital warts, treated with an immune response modifier, 5% imiquimod cream, and followed up to 6 months after total clearance. METHODS: This was an open, non comparative, multicenter study conducted in 51 private or hospital practices in France. 5% imiquimod cream was applied 3 times per week until the clearance of external genital warts, with a maximum application period of 16 weeks. Patients were followed-up for 6 months after complete clearance. RESULTS: One hundred ninety-one patients (103 males and 88 females), with a mean age of 31.4 years (18.1-70.4) were included in this study, between November 29 1999 and February 1st 2001. Complete clearance of external genital warts was noted in the ITT analysis in 103/191 cases (54 p. 100; CI95 p. 100: 40-61). Fifteen out of 92 (16 p. 100; CI95 p. 100: 9.4-25.5) had a recurrence within the 6 months follow-up period, 13 of these 15 recurrences were noted at the 3 month follow-up visit. CONCLUSION: The rate of recurrence of external genital warts at 6 months was similar to the rate noted at 3 months, suggesting that after the 3-month period, the risk of developing a recurrence was low. The mode of action of imiquimod through the induction of cytokines and the stimulation of the local immune response could explain these results.

Intravenous immunoglobulin for adults with autoimmune thrombocytopenic purpura: results of a randomized trial comparing 0.5 and 1 g/kg b.w.

Since the first reports demonstrating the ability of a total dose of 2 g/kg body weight (b.w.) of intravenous immunoglobulin (IVIg) to increase the platelet count in patients with autoimmune thrombocytopenic purpura (AITP), the optimal dose has remained controversial. We report the results of a randomized study which compared two low doses of IVIg (0.5 g/kg b.w., group A, n = 19, and 1 g/kg b.w., group B, n = 18) in 37 adults with AITP and platelet count <50 x 109/l, in preparation for surgery or in a situation with a risk of bleeding. On day 4 the proportion of responses, defined by a platelet count > 80 x 109/l and at least twice the initial platelet count, was significantly higher in the group receiving 1 g/kg b.w. (12/18 in group B versus 4/19 in group A, P = 0.005). All but one of the day 4 responders had already responded on day 3. The daily changes in the platelet count from the beginning of IVIg treatment were larger in group B, with a significant difference relative to group A on day 3 (92 x 109/l in group B versus 50 x 109/l in group A, P = 0.03) and on day 4 (106 x 109/l in group B versus 55 x 109/l in group A, P = 0.03). Patients who had not responded by day 4 subsequently received 1.5 g IVIg/kg b.w. (group A) or 1 g IVIg/kg b.w. (group B). A response was observed in 11/13 initial non-responders in group A, and in 2/6 initial non-responders in group B. Finally, on day 8, the proportion of responders was 78% (29/37) in the entire group and was similar in the two subgroups. In conclusion, (1) initial treatment with 1 g/kg b.w. of IVIg appeared to be more effective than 0.5 g/kg b.w. in adults with AITP; (2) infusion of a low dose of IVIg did not jeopardize the efficacy of IVIg reinfusion; (3) some adults who did not respond to 1 g IVIg/kg b.w. responded to a higher dose.

Red blood cell aggregation and microcirculation in rat cremaster muscle.

Using intravital microscopy of the rat cremaster muscle, we studied the effects of changing red blood cell (RBC) aggregation on RBC arteriolar velocity and perfused capillary density (PCD). To modify RBC aggregation, 2 and/or 10% dextran (molecular weights 40,000, 70,000 or 480,000) or fresh rat plasma was infused into adult male rats via a normovolemic hemodilution procedure. The high-molecular-weight dextrans (70,000 and 480,000) both induced RBC hyperaggregation associated with similar dose-dependent decreases in RBC arteriolar velocity (30 and 40% for dextran concentrations of 2 and 10%, respectively) and in PCD (35 and 37%, respectively, for the two concentrations). Conversely, with 40,000 molecular weight dextran or plasma, we observed a 30% increase in RBC arteriolar velocity, but no change in PCD or hyperaggregation. Intravenous injection of the antiaggregating drug troxerutin (10(-3) M), either before or after 2% dextran 70,000, significantly inhibited the effects of this dextran on RBC arteriolar velocity and on PCD. We conclude that RBC hyperaggregation can lead to changes in both arteriolar velocity and PCD and may, therefore, impair tissue oxygenation.